My purpose in this qualitative study was to build on the existing literature of phenomenological studies regarding the lived experiences of health care professionals, including nurses, who experience patient death (Velarde-Garcia et al., 2016) by exploring the lived experiences of transport nurses who have experienced patient death. To address this gap in the current evidence of transport nurses’ experiences, I conducted a qualitative phenomenological study using semistructured interviews. Findings from my study may be used by transport nurses, administrators, and other transport providers to gain an understanding of how those working in this unique environment may be affected by patient death. This may lead to social change within organizations where transport nurses may share their experiences to help create both social support and effective coping strategies for addressing patient death. I conducted semistructured interviews with eight transport nurses sharing their experiences of patient death. Key findings from my study included five major themes that described the lived experiences of transport nurses experiencing patient death. These themes included: What if?, Why this Patient?, Partnerships and Partner Bonds, Debriefing Process, and Protective Mechanisms.
Interpretation of the Findings
As a theoretical lens having driven my study, life-world by Husserl allowed individuals to describe and shed light on phenomena as described by their lived experiences. (Barrientos & Holmberg, 2018). This study enabled transport nurses to describe their lived experiences of patient death in a way that shed lights on the
phenomena of death in this unique environment. Findings from my study aligned with previous research surrounding patient death as experienced by health care providers, including nurses. In a study examining the coping mechanisms of ICU nurses after a patient death, Bayou and Agbenorku (2018) suggested that death may often lead to feelings of sadness and lack of accomplishment. Participants in this study experienced similar feelings of sadness, shock and feeling gutted after the death of a patient. This also extended to self-doubt, regret, and questioning the care they provided which may have affected the patient’s outcome.
A key difference of note among all participants was a lack of support and time when caring for a patient in a pre-hospital setting. Due to short transport times, small work spaces, minimal supplies, and a lack of traditional medical and ancillary support found in a hospital setting, experiencing a patient death is often more difficult. As highly trained professionals with increased levels of autonomy and responsibility for critical care and trauma management, the effect of being the primary decision maker as a transport nurse in life and death situations varied greatly from experiences within a hospital. Rather than a collective or shared experience of “blame” or “doubt” among medical professionals after a patient death, transport nurses often had an inherent fear of making the wrong decisions that may ultimately affect the patient’s outcome. This also led to a sense of responsibility for a patient’s death even though all measures to save their life were exhausted and out of their control.
A new finding not previously seen in the literature was the difference in experiences of patient death in an acute care setting versus a transport setting. Seen as
expected or anticipated, death in an acute care setting was often easier to deal with. Having the appropriate resources, adequate working space, and personnel necessary to care for a patient, the outcome of death, despite those measures, was often easier to accept and deal with. This varied greatly in how nurses experienced patient death in the transport setting. Most deaths in the prehospital setting were unexpected and patients often had severe injuries or decompensated rapidly despite not appearing acutely ill or injured. Despite best efforts being made to save the patient’s life, an increased sense of doubt and self-blame was experienced as transport nurses carry an increased level of responsibility and autonomy when caring for patients in the transport environment. As years of experience and the number of patient death they experienced increased, transport nurses were better able to accept the dying process and embrace the outcomes patients faced. This included providing compassionate and end of life care, communicating to the dying patient and relaying the care giving to family members after the patient died.
Participants of my study also described partnerships and bonds among their colleagues and the importance having them were. Bonding, teamwork, and trust was fostered among transport providers who experienced a patient death together. This concept was reflective in the literature as described by Hogan et al. (2016) and
MacDermott and Keenan (2014) who described the importance of sharing experiences with peers as paramount to processing death and returning back to the bedside. Although death affects individuals differently, coping may be facilitated through peer support (Lindsay & Heliker, 2018; Khalaf et al., 2017). A key finding of note, however, was that transport nursing is a unique setting that varies greatly from working at the bedside in an
acute care facility, therefore affecting how peer interactions may occur. Transport nurses often work with one other person and may include a paramedic, respiratory therapist, or another transport nurse for extended periods of time. Shifts may range from 12 hours to 72 hours in length and consist of lengthy or multiple transports occurring back to back. Small working spaces, minimal resources, the intensity of patient transports, and increased levels of autonomy facilitate shared experiences among partnerships, which often lead to turning to one another for comfort and support when faced with difficult situations like patient death.
An additional finding coinciding with the literature was the lack of a formal debrief process. My study concluded that although a debrief process was viewed as important, it’s occurrence rarely happened. Those individuals who completed a debrief, even among themselves, indicated that professional bonds were strengthened and returning to work became easier. MacDermott and Keenan (2014) concluded that with administrative support, nurses may better manage grief which allows for them to enhance their future care to patients and families. Similarly, Bacon (2017) stressed the importance of administration and management involvement when staff experience patient death, which may help lead to education to provide guidance and support. Regardless of the type of debrief, its duration, or frequency of occurrence, all participants recognized the importance and need for a formal debrief process following the death of a patient. Whether a debrief is completed among the crew caring for the patient, administrative personnel, or a medical director, its success hinges on fostering a stigma-free
My study also revealed how transport nurses created protective mechanisms to protect their feelings and create emotional barriers. This included purposely avoiding the creation of relationships with patients especially when anticipating a poor outcome such as death. As transport providers with an increased level of decision making,
responsibility, and autonomy when caring for critically ill and injured patients, outcomes from this study aligned more closely with physicians. This included similarly shared views of increased expectations, responsibilities, and personal competency as a primary care provider. This was supported by the literature as described by Whitehead (2014) who described his phenomenological study of the lived experiences of physicians dealing with iatrogenic patient death. Whitehead discovered underlying themes that expectations and responsibilities of providing care and questions of competency. Often when death did occur, physicians questioned their own competency as a practitioner (Whitehead, 2014).
Limitations of the Study
There were limitations to my study. My study included transport nurses with a wide-range of experience who worked in diverse settings and geographic regions; however, their experiences may not represent the experiences of all transport nurses. With qualitative inquiry there is a risk of researcher bias being introduced. As a full-time transport nurse who has experienced multiple patient deaths, my personal feelings and experiences potentially created bias during the interview process and data analysis. To avoid this, an independent analysis of the interview transcripts was conducted by my dissertation chair to ensure no personal bias influenced the interviews or data analysis. Current volunteer work on the board of directors for ASTNA created a likelihood that
research participants would be familiar with my own employment as a transport nurse and role in the transport community. Knowledge of these roles could have potentially influenced their interaction and responses during the interview process.
Recommendations
I undertook this study to bring awareness to the transport community concerning the affect that patient death has on transport nurses. Although similarities in the literature existed surrounding death in acute care and prehospital settings, this unique population and unique working environment must be recognized and addressed. Although
participants shared similar experiences surrounding patient death, a common area discussed was the recognition of the lack of a formal process for a debrief after a patient death. Recognizing that debriefing based on the type of transport is integral in enabling transports team to discuss difficult patient transports, even if the call did not end in death. When the effect of a difficult call including patient death is profound, immediate support for transport teams is recommended. This may include a formal, robust debrief either immediately following the incident, or shortly thereafter. This debrief process may include the transport team, base manager or administrative representative, and medical director. Giving transport personnel the ability to physically and emotionally step away from patient care and allowing them the opportunity to simply collect their thoughts, discuss the call, the care they provided, and any difficulties faced may prove beneficial.
Recommendations for a formal debrief process are encouraged to be adopted by transport programs to allow transport providers a safe environment to discuss patient death. Peter et al. (2013) suggested that the nurse’s role in a patient death is often
exhausting and compels nurses to be reflective on how they both deal with and process death. This environment may be created immediately following a patient death, or in the near future depending on the individual needs of the transport provider. Creating a formal debrief process may afford transport nurses the opportunity to discuss patient death and the care they provided surrounding that particular transport. By having a formal
discussion, transport nurses may share their feelings surrounding the care they provided which may help decrease frequent emotions including self-doubt and questioning of the care they provided. This may assist in helping to affirm and support the decisions that were made during the transport. In turn, this may lead to stronger bonds among transport teams and mitigating the creation of protective mechanisms such as building emotional barriers that could may affect future patient care.
A lack of literature describing the lived experiences of transport nurses
experiencing patient death led to the creation of my study. Based upon the data collected from transport nurses experiencing patient death, recommendations for further research are indicated and include: a large-scale study to validate the findings, which may include conducting interviews with transport nurses outside of the United States, and conducting interviews with other transport personnel including paramedics, respiratory therapists, or physicians.
Implications
Results from my study are supported by the literature that health care providers, including nurses, are affected by patient death. Transport nurses share many of the same experiences of patient death faced by other health care providers; however, there are
significant differences that must be noted. These differences include an increased sense of responsibility and autonomy which may lead to self-doubt and questioning of
competency in the event a patient dies during transport or transfer of care. Addressing these feelings in a formal debrief may facilitate communication among team members, administrative personal, and medical directors to offer insight and assurances that
although the patient died, care was provided to the best of their ability. Regardless of the experience of patient death, partnerships and bonds among team members can be
strengthened as they work to support one another. Often after experiencing the death of a patient, protective mechanisms are created to help limit emotional attachment and
decrease the likelihood of bonding with a patient who may suddenly die. These protective mechanisms may be mitigated if transport nurses are able to formally debrief patient transport ending in patient death and allowed the opportunity to discuss their feelings, either immediately afterwards, or in the near future.
My study has implications for social change as it provides much-needed research in an area that has not been previously studied. With this information, individuals and transport programs may work to create awareness and education regarding patient death and the affect it may have on individuals. By having knowledge of patient death and the unique affect it has on transport nurses, transport providers may better understand how they function in their role as a caregiver in the event a patient dies. This may affect how they interact with their colleagues which may lead to forming lasting personal and
professional bonds. Ultimately, this knowledge may be used to educate future generations of transport professionals to provide insight and understanding into how death may affect
them. Armed with this knowledge, administrative support can recognize the importance supportive measures like formal debriefings may in helping to deal with difficult transports that include patient death. By providing insight into the lived experiences of transports nurses experiencing patient death, transport nurses, their management, and the transport industry as a whole may have a better understanding of how death affects this unique population. Husserl (1970/1954) describes the practical application of life-world as allowing individuals to see that human beings are aware of their surrounding world, how they live in that world, and how having experiences can directly affect their
surroundings. My study offers valuable information that may help the transport industry to recognize the affect death has on individuals and the steps that may be taken to assist in the coping process and longevity of a transport nurse’s career.
Conclusion
My study examined the experiences of transport nurses experiencing patient death and shed light on its effect on both personal and professional lives. By gaining a better understanding of death in the transport environment, positive social change may be promoted by educating and encouraging transport programs to create coping strategies and formal processes to assist in dealing with the affect that patient death may have on transport nurses.
Death is an inevitability that all individuals must face in their life-time. As medical professionals, transport nurses are in a unique and humbling position to be present with another human being in their final moments of life. Whether death is
patients. Education and self-care are vital for transport nurses to continue their work of saving lives in this unique and challenging environment. Despite exteriors of calm and collectedness, we owe it to ourselves to recognize that we are fallible human beings that can be affected by those for whom we care and in order to continue that legacy, we must first care for ourselves.
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